Anti-NMDAR Encephalitis: A Multidisciplinary Approach to Identification of the Disorder and Management of Psychiatric Symptoms.

BACKGROUND: The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently been developed, has led to a lack of information on assessment and treatment of its variable behavioral manifestations. METHOD: In this article, we discuss 4 challenging cases of anti-NMDAR encephalitis, focusing on the importance of a multidisciplinary approach to identification and management of the disorder and the necessity of close collaboration in the acute hospital setting for management of the behavioral symptoms. CONCLUSION: The cases we discuss highlight some of the medication and nonpharmacologic treatment strategies that may facilitate management of psychiatric symptoms, both while the medical workup is ongoing and after the diagnosis has been confirmed.

Prolonged Hypercalcemia-Induced Psychosis.

Hypercalcemia is known to cause neuropsychiatric dysfunction including mood and cognitive changes and rarely, acute psychosis. High calcium levels can be a catalyst for neuronal demise, possibly due to glutaminergic excitotoxicity and dopaminergic and serotonergic dysfunction. While restoration of normal calcium levels or removal of a parathyroid adenoma has been shown to rapidly resolve neuropsychiatric symptoms, there have been rare reported cases of primary hyperparathyroid-related hypercalcemia with persistent symptoms of psychosis. In this case report, we will describe a patient with no past psychiatric history presenting with a protracted course of delirium and psychosis after a removal of a parathyroid adenoma which had caused prolonged exposure to hypercalcemia. The patient's psychosis was unresponsive to psychotropic medication and required inpatient psychiatric care after medical clearance. Per medical records, before the patient was ultimately lost to follow-up, she continued to suffer from psychotic symptoms for at least 8 months. We will discuss the patient's unusual hospital course and management and offer suggestions for future study.

Practice Change After Training Psychiatry Residents in Tobacco Use Disorder.

The goal of this study was to evaluate treatment practices among psychiatry residents before and 3 months after a course on tobacco use disorder. After completing the course, residents (N=89) reported a significant increase in the frequency in nine of the 12 tobacco use disorder treatment practices studied. Participants reported being more likely to assess patient willingness to quit smoking, advise patients to stop smoking, prescribe treatment medications, and provide cessation treatment. Being a junior vs. senior resident was a significant predictor of increased practices. Completing online training was associated with significant increases in the use of specific tobacco treatments.

Aspirin misuse: a case report.

Aspirin-use disorder is an underreported condition. Identification of the signs and symptoms of aspirin misuse are important in light of prevalent non-prescribed medicine/over-the-counter medication (NPM/OTC) misuse. We discuss here the case of a patient with a history of chronic aspirin misuse who presented to the emergency department with salicylate intoxication and described elation secondary to deliberate aspirin consumption. This case highlights the importance of screening for NPM/OTC medication misuse in at-risk populations.

Evaluation of an Online Residency Training in Tobacco Use Disorder.

BACKGROUND AND OBJECTIVES: Despite the overwhelming need for tobacco use disorder (TUD) treatment in behavioral health settings, few models have emerged for training psychiatry residents. One barrier may be a lack of curricula or faculty expertize in this area. The goal of this project was to develop and evaluate a 3 hour online webinar-based course for teaching psychiatry residents about TUD. METHODS: Residents from 42 participating general psychiatry residency programs were emailed a unique link to course materials. Participation was voluntary. RESULTS: Two-hundred and seven residents completed the pretest measuring baseline knowledge and 199 completed the survey measuring attitudes toward treatment of tobacco use. Mean pretest scores were 53.0% correct (SD 19.6), showing low levels of baseline knowledge. Pretest knowledge scores differed by residency year, suggesting no gain in knowledge during residency training. About 80% of participants completed the entire course and posttest evaluations. Paired t tests for 150 individuals who completed both a pretest and posttest indicated a significant increase in knowledge, with a mean gain in score of 35 points. DISCUSSION AND CONCLUSIONS: Many residents reported feeling not well prepared to treat TUD from prior education. The vast majority (98%) felt the program enhanced their professional experience somewhat or substantially or would recommend the program to others (82%). SCIENTIFIC SIGNIFICANCE: Online training for residents is a viable option to address knowledge deficits in TUD. (Am J Addict 2019;28:277-284).

Mindfulness Meditation for Medical Students: a Student-Led Initiative to Expose Medical Students to Mindfulness Practices.

PURPOSE: To explore the feasibility and impact of a brief mindfulness training for medical students and to learn about the perceptions, expectations, and problems associated with mindfulness practices in the context of medicine and medical education. METHOD: Forty-one medical students were randomized into either an introductory mindfulness class only or an introductory mindfulness class plus an 8-week mindfulness meditation course. Quantitative and qualitative data were collected from both groups after the introductory class and again after the full course. Qualitative data was subject to close iterative reading as part of a grounded-theory-guided content analysis, generating a list of codes which were then assigned to statements and arranged into overarching themes. RESULTS: Mindfulness and awareness were negatively correlated with stress and depression. Students who took the full mindfulness course emerged with a greater familiarity with and willingness to utilize mindfulness modalities. There was no significant difference on wellness outcomes between the introductory-course-only group and the full-mindfulness-course group. Thematic analysis revealed student aspirations for a mindfulness alternative in medicine and medical education but also a recognition of the challenges inherent in applying such an alternative. CONCLUSION: A mindfulness course for medical students is feasible and has potential as a wellness and educational initiative. Shorter duration mindfulness interventions may increase accessibility without significantly reducing benefit. Interpretation of overarching themes derived from the grounded theory analysis illuminates the subject of mindfulness for medical students from the perspective of students themselves.

Trastornos de bipolares y comorbilidades - consideraciones éticas en deportes / Bipolar disorders and comorbid conditions - Ethical considerations in sports

Introducción: El objetivo de la intervención farmacológica es el resultado terapéutico: máxima eficacia con mínimos efectos adversos. Esto resulta difícil a la hora de tratar el trastorno bipolar, debido a las comorbilidades y/o fármacos complementarios necesarios para abordar los efectos adversos. La polifarmacia racional óptima puede maximizar el resultado terapéutico, aunque podría crear cuestiones éticas en los deportes competitivos. El Código Mundial Antidopaje (WADC) y la Lista de Sustancias Prohibidas de la Agencia Mundial Antidopaje, publicada anualmente, tienen como objetivo disuadir y sancionar a los atletas que utilicen agentes para mejorar el rendimiento, y promover un marco de igualdad para todos los competidores. Este documento presenta tres ejemplos hipotéticos (TDAH/temblor secundario al litio/dolor) en los que la contravención no deliberada de la Lista de Sustancias Prohibidas derivaría en descalificación por violación de la norma antidopaje sin aprobación de las Exenciones por Uso Terapéutico (TUEs). Método: Análisis de caso hipotético con revisión de la literatura. Resultados: TDAH Comórbido: la Lista de Sustancias Prohibidas excluye los psicoestimulantes (metilfenidato/anfetaminas) en la competición (S6) pero permite guanfacina/atomoxetina. En los casos en que los psicoestimulantes constituyeran un tratamiento eficaz para el TDAH en los atletas con trastorno bipolar, a diferencia de guanfacina/atomoxetina, estos pacientes-atletas deberán presentar TUEs, junto con la certificación y documentación de respaldo del clínico. Temblor secundario al Litio: a menudo se prescriben beta-bloqueantes para controlar el temblor secundario al litio, pero que no están autorizados para deportes específicos (P2). En caso de que los fármacos alternativos (primidona) resulten ineficaces, serán necesarias las TUEs. Dolor: el manejo del dolor crónico es difícil en atletas, ya que los analgésicos narcóticos (S7) y cannabinoides (S8) están prohibidos en la competición. Cuando el dolor comórbido no se controla con fármacos autorizados, son necesarias las TUEs. Conclusión: Los pacientes-atletas con trastorno bipolar y comorbilidades precisan enfoques holísticos, con reconocimiento tanto del WADC como de la Lista de Sustancias Prohibidas. Los atletas deberían realizar un listado de todos los fármacos incluyendo diagnósticos/obtener TUEs/verificar el estado de la medicación propuesta (prohibido/restringido/permitido) con las Federaciones Internacionales adecuadas y/u Organizaciones Olímpicas. Los clínicos deberán ser conocedores de estas cuestiones a la hora de tratar a los pacientes-atletas

Introduction: The goal of pharmacologic intervention is therapeutic outcome: maximal efficacy with minimal adverse effects. In treating bipolar disorder, this may be complicated by comorbidities and/or adjunctive medications required to address adverse effects. Optimal rational polypharmacy may maximize therapeutic outcome yet could create ethical issues in competitive sports. The World Anti-Doping Code (WADC) and yearly published World Anti-Doping Agency Prohibited List are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. This paper presents three hypothetical examples (ADHD/lithium-tremor/pain) wherein unintended Prohibited List contravention would result in doping violation disqualifications without approved Therapeutic Use Exemptions (TUEs). Method: Hypothetical case analyses with literature review. Results: Comorbid ADHD: the Prohibited List precludes psychostimulants (methylphenidate/amphetamines) in competition (S6) but permits guanfacine/atomoxetine. When psychostimulants effectively treat ADHD in athletes with bipolar disorder but guanfacine/atomoxetine do not, these patient-athletes, with clinician’s certification and supportive documentation, should file TUEs. Lithium-tremor: beta-blockers are frequently prescribed to control lithium-tremor but are not permitted for specific sports (P2). If alternatives (primidone) are ineffective, TUEs are indicated. Pain: chronic pain management is difficult in athletes as narcotic analgesics (S7) and cannabinoids (S8) are prohibited in competition. When comorbid pain is not controlled with approved medications, TUEs are required. Conclusion: Patient-athletes with bipolar disorder and comorbidities require holistic approaches with appreciation of both the WADC and Prohibited List. Athletes should list all medications with diagnoses/obtain TUEs/verify proposed medication status (banned/restricted/permitted) with appropriate International Federations and/or Olympic organizations. Clinicians should be cognizant of these issues when treating patient-athletes

Corrigendum to "A Case of Sporadic Creutzfeldt-Jakob Disease Presenting as Conversion Disorder".

[This corrects the article DOI: 10.1155/2017/2735329.].

Teaching Empathy: the Implementation of a Video Game into a Psychiatry Clerkship Curriculum.

OBJECTIVE: Empathy plays an important role for physicians, but the literature demonstrates that it often deteriorates during medical school. The purpose of this study is to investigate the use of the interactive video game "That Dragon, Cancer" as a tool to teach empathy to third-year medical students. METHODS: The authors gave a modified, Jefferson Scales of Physician Empathy (JSPE) to 84 third-year medical students in their psychiatry clerkship before and after they played and completed "That Dragon, Cancer" during the 2016-2017 academic calendar year. RESULTS: The average level of empathy in the students as measured by least squares means of the answers to the truncated JSPE improved after playing through "That Dragon, Cancer" (5.7738 vs 6.2322, p < 0.0001). The majority of students agreed that learning empathy through video games was preferable and more effective than traditional didactics. CONCLUSIONS: Interactive video games such as "That Dragon, Cancer" may be useful as part of innovative curricula to improve empathy among third-year medical students.

Delusional parasitosis on the psychiatric consultation service - a longitudinal perspective: case study.

BACKGROUND: Delusional parasitosis is infrequently seen in hospital-based consultation-liaison psychiatry. AIMS: Although there are many publications on delusional parasitosis, this report reviews a unique case that was diagnosed during a hospital admission and treated over the next 36 months. METHOD: Case report and literature review. RESULTS: This case report describes a 65-year-old man who was diagnosed with delusional parasitosis during a hospital admission for congestive heart failure and acute kidney injury. A longitudinal description of the patient's condition during the hospital stay and in the 36 months following discharge, during which time he was treated by a consultation psychiatrist, is provided. CONCLUSIONS: In discussing the treatment of a challenging presentation, this case demonstrates the opportunity for consultation psychiatrists to initiate care in patients who might not otherwise seek psychiatric services. Patients with somatic delusions represent one group of patients who are unlikely to independently seek psychiatric treatment. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

A Case of Sporadic Creutzfeldt-Jakob Disease Presenting as Conversion Disorder.

Background. Creutzfeldt-Jakob disease is a rare disorder of the central nervous system. Its initial diagnosis may be obscured by its variable presentation. This case report illustrates the complexity of diagnosing this disease early in the clinical course, especially when the initial symptoms may be psychiatric. It offers a brief review of the literature and reinforces a role for consultation psychiatry services. Methods. PUBMED/MEDLINE was searched using the terms "Creutzfeldt-Jakob disease", "psychiatric symptoms", "conversion disorder", "somatic symptom disorder", "functional movement disorder", and "functional neurologic disorder". Case. The patient was a 64-year-old woman with no prior psychiatric history who was initially diagnosed with conversion disorder and unspecified anxiety disorder but soon thereafter was discovered to have Creutzfeldt-Jakob disease. Discussion. This case highlights the central role of psychiatric symptoms in early presentations of Creutzfeldt-Jakob disease. Still, few other cases in the literature report functional neurological symptoms as an initial sign. The consultation psychiatrist must remain alert to changing clinical symptoms, especially with uncharacteristic disease presentations.

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.

Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.

Psy-feld: An Innovative Didactic Using the TV Show Seinfeld to Teach Delusional Disorder Subtypes.

OBJECTIVE: The primary purpose of this article is to introduce Psy-feld, an innovative didactic used to review mental disorders through discussion of the interpersonal relationships of the fictional characters created in Larry David's situational comedy, Seinfeld. To introduce this novel didactic, several peripheral Seinfeld characters were selected, who while not afflicted with a psychotic disorder, demonstrate traits that serve to facilitate discussion to review the different subtypes of Delusional Disorder. METHODS: Psy-feld is a 30-min faculty-facilitated didactic where a selected episode of the sitcom allows for review of multidisciplinary content areas considered germane to the practice of psychiatry. At Rutgers-Robert Wood Johnson Medical School, 104 third-year medical students rotated on the Consultation-Liaison Service from July 2011-March 2014 and participated in Psy-feld. RESULTS: Of the 104 students who participated in Psy-feld, 99 completed surveys on the didactic. Students found the didactic to be of high quality, believed it enhanced their learning, and thought that it prepared them for their final SHELF exam. Students also found it enjoyable and preferred the didactic to more traditional forms of teaching such as large group lectures. CONCLUSIONS: Psy-feld is an example of an innovative teaching method that medical students found informative in reviewing teaching points of Delusional Disorder.